APPLICATION TO THE GERIATRIC PSYCHIATRY FELLOWSHIP,
DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER
GENERAL INFORMATION
Last
Name
Birth
Date
Present Mailing
Address
Permanent Home
Address
First
Name
Birth
Place
□ Male □ Female
Middle
Name
Social Security Number
Citizenship
Home
Telephone #
Work/Office
Telephone #
PRE-MEDICAL EDUCATION
Name of Institution
City, State, Country
From
(mo/yr)
To
(mo/yr)
Degree
City, State, Country
From
(mo/yr)
To
(mo/yr)
Degree
High School
Undergraduate
Graduate
Other
MEDICAL EDUCATION
Name of Institution
USMLE
Scores
Step 1
Step 2
Step 3
COMPLEX
Scores
Level 1
Level 2
Level 3
Honors (Undergraduate, Graduate, Medical School):
(Honors, continued)
Most Recent Hospital Affiliation:
INTERNSHIPS, RESIDENCIES, FELLOWSHIPS, TEACHING APPOINTMENTS (list most recent date first)
Name of Institution
Service or Specialty
From
(mo/yr)
City, State, Country
To
(mo/yr)
Honors (for above):
PROFESSIONAL RECOMMENDATIONS (please list at least three)
Address letters to: William Apfeldorf, MD – c/o Kristi Johnson
Department of Psychiatry, UNM-SOM
1 University of New Mexico MSC09 5030
Albuquerque, NM 87131
1) Name:
Professional Relationship: Psychiatry Residency Training Director
Address:
Telephone:
2) Name:
Professional Relationship:
Address:
Telephone:
3) Name:
Professional Relationship:
Address:
Telephone:
4) Name:
Professional Relationship:
Address:
Telephone:
State/Province
PROFESSIONAL LICENSURE
Type of License
Date Issued
License #
Check one
□ Permanent □ Temporary
□ Permanent □ Temporary
Geriatric Psychiatry Fellowship Application, UNM HSC, Page Two
ADDITIONAL INFORMATION
Language Fluencies:
Cultural Competencies:
Special Skills:
Military
Status:
Military Obligation:
□ Completed □ Pending □ None
WRITTEN STATEMENT
Please attach a personal statement. We suggest that you consider including the following:
 a biographical sketch, including the development of your interest in geriatric psychiatry;
 your previous clinical experience with geriatric population;
 your research experience or additional relevant accomplishments;
 your special areas of interest and/or theoretical orientation in geriatric psychiatry;
 your educational goals for your geriatric psychiatry fellowship;
 your eventual career goals following your fellowship;
 your interest in the geriatric psychiatry fellowship at the University of New Mexico
 any other information which you would like us to consider.
FOREIGN MEDICAL GRADUATES
ECFMG
Information
□ Interim □ Standard
Basic Science
Score
Certificate #
TOEFL Examination Information
TOEFL Exam Taken:
FMGEMS Examination Information
FMGEMS Exam Taken:
□
United States Visa Status:
Currently possess a US visa
(US Visa Status – comments):
□ Yes □ No
□ Yes □ No
Clinical Science
Score
English
Score
Please enclose a copy of your
ECFMG exam certificate.
If you took the TOEFL, please enclose a copy of your TOEFL exam certificate.
If you took the FMGEMS, please enclose a copy of your FMGEMS exam certificate.
□ Application in progress □ Exchange visitor □ Permanent □ Immigrant □ Refugee □ Other - please describe below
APPLICATION INSTRUCTIONS
Attach a recent 2 ½ x 3 inch photograph where indicated below.
Request that letters of recommendation be sent to us from the references you have listed on this application.
Request that an official copy of your medical school transcript(s) be sent to us (the address is listed in #6 below).
Request transcript of your USMLE or COMPLEX be sent to us (the address is listed in #6 below).
Complete, sign, and date this application.
Send this application, along with your personal statement, a current curriculum vitæ, and any other requested information, to:
William Apfeldorf, MD
Training Director
c/o Kristi Johnson
MSC09 5030
1 University of New Mexico
Albuquerque, NM 87131-5326
If you have any questions about the application process please contact the Medical Residency Coordinator, Andrea D. Chapman, either
by telephone at (505) 272-5002, or by email at adchapman@salud.unm.edu . We will contact you when your application file is
complete. Thank you for your interest in our fellowship.
SIGNATURE AND PHOTOGRAPH
1)
2)
3)
4)
5)
6)
Signature of Applicant:
Date:
__________________________________________________
_____________________________
Recent Photograph
2 ½ x 3 inches
Color or black & white
Malpractice/Discipline Actions
A. Malpractice
If there have been settlements, malpractice claims, and/or lawsuits pending or closed during the previous 10
years, please describe on a separate page.
B. Miscellaneous
a. Has your professional license in any state ever been revoked, suspended, canceled or restricted?
Yes
No
b. Have you ever been denied a professional license in any state?
Yes
No
c. Have you ever been requested to appear before any professional society or licensing board because of a
complaint or charge?
Yes
No
d. Have you ever had any action against you by the Narcotics Bureau of the Treasury Department, or a
Federal, State or local drug enforcement agency or had your DEA permit denied or revoked?
Yes
No
e. Has your status as a member of the staff of any hospital, clinic or other facility, or the scope of your
privileges at any such facility, ever been decreased or terminated, for any reason?
Yes
No
f. Has a mental or physical impairment lasting more than one month ever interfered with your education
or professional duties within the last 10 years?
Yes
No
g. Are you now, or have you ever been, dependent upon the use of alcohol, stimulants or other habitforming drugs?
Yes
No
h. Have you ever been convicted of a felony in a criminal action?
Yes
No
Important: If you answered “Yes” to any of the above questions, please attach a written explanation.
Applicant’s affidavit:
I certify that all the information contained in this application is correct to the best of my knowledge. I
authorize investigation of all matters contained in this application and agree that any misleading or false
statements would be cause for rejection of this application or would be sufficient cause for dismissal after
my appointment.
Signature of Applicant:
Date: